TOPIC: Orthostatic Hypotension Treatment With Head end of the bed Raised

Orthostatic Hypotension Treatment With Head end of the bed Raised
1 year 11 months ago #1393

Postal questionnaire survey: the use of sleeping with the head of the bed tilted upright for treatment of orthostatic hypotension in clinical practice
Chie Wei Fan, Davis Coakley, J. Bernard Walsh, Conal J. Cunningham

SIR—Orthostatic hypotension (OH) is common and affects one in five community-living older persons [1]. The incidence is higher amongst older in-patients [2] and those attending a syncope clinic [3].

The treatment of OH is through increasing peripheral vascular resistance and/or intravascular volume. Existing treatments such as increased water intake, salt replacement [4] and medications may lead to hypertension, and older people tend to tolerate these interventions poorly [5]. Drinking 2–2.5 l of fluids daily may be effective in younger patients [6, 7] but may be undesirable in older patients who can be prone to urinary incontinence.

Sleeping with the head of the bed elevated (SHU) is established as part of the treatment modality for OH [6, 8, 9]. The European Society of Cardiology guidelines [9] recommend raising the head of the bed on blocks to permit gravitational exposure during sleep, which results in chronic intravascular volume expansion. Mathias and Bannister [10] recommend SHU as first-line treatment for OH in patients with autonomic failure (AF).

Our literature review suggests that SHU at 12° or greater confers some benefit in patients with OH. However, the studies were small with sample sizes of eight subjects or less with varying ages (23–66 years), and the majority of the patients had AF (Table 1). A number of those studies used a combination of SHU, fludrocortisone, and increased water and salt intake, so identifying the exact contribution from SHU is often not possible. The improvement in orthostatic blood pressure (BP) with SHU from the studies is summarised in Table 1.
academic.oup.com/ageing/article-lookup/d...0.1093/ageing/afl073

Results: symptoms improved, to a similar extent, in both groups. There were no differences in MAP or other haemodynamic parameters, weight, urinary volume or 24-ABPM between SHU and controls. SHU were more likely to have leg oedema.

Conclusions: these findings suggested that SHU at 6 inches has no additional effects on symptoms or haemodynamic parameters at 6 weeks than existing non-pharmacological measures in older patients with OH. Its use in this group should therefore be discouraged.
academic.oup.com/ageing/article/40/2/187...-the-head-of-the-bed

This study was designed to examine the effect of head-up sleeping as a treatment for vasovagal syncope in otherwise healthy patients. Treatment for syncope is difficult. Pharmacological treatments have potential side effects and, although other non-pharmacological treatments such as salt and fluid loading often help, in some cases they may be ineffective or unsuitable. Head-up sleeping may provide an alternative treatment.
Methods

Twelve patients had a diagnosis of vasovagal syncope based both on the history and on early pre-syncope during a test of head-up tilting and graded lower body suction. They then underwent a period of 3–4 months of sleeping with the head-end of their bed raised by 10°, after which orthostatic tolerance (time to pre-syncope during tilt test) was reassessed.
Results

Eleven patients (92%) showed a significant improvement in orthostatic tolerance (time to pre-syncope increased by 2 minutes or more). Plasma volume was assessed in eight patients and was found to show a significant increase (P < 0.05, Wilcoxon signed-rank test). There was no significant change in either resting or tilted heart rate or blood pressure after head-up sleeping.
Interpretation

Head-up sleeping is a simple, non-pharmacological treatment which is effective in the majority of patients. However, it may not be tolerated by patients or bed-partners long term and whether the effects continue after cessation of treatment remains to be determined.
Keywords
syncope head-up sleeping plasma volume blood pressure
link.springer.com/article/10.1007/s10286-008-0494-8